Medicare Advantage Fraud: New Medicare Rule Aims to Take Back $4.7 Billion From Insurers - NYT

 I'm sharing articles on MedAdv fraud to give us weapons to use in fighting back when our union leaders claim MedAdv is just medicare part c.

MedAdv fraud drains billions from Medicare and helps undermine it. This also addresses calls to cut Medicare. Republicans may point to this fraud as a good reason. But the counter is that by pulling back these billions from insurance companies that is saving money. Last week we heard the lobbying efforts were successful in keeping them from going after the money. But this is only fraud from 2018 - and there was some efforts by the Trump admin to address this issue. We know both parties are subject to the industry lobbying.  There are calls to get money back from 2011 but that is not going to happen.

Norm

New Medicare Rule Aims to Take Back $4.7 Billion From Insurers

The government plans to aggressively audit Medicare Advantage plans for overbilling but may face lawsuits.

 

https://www.nytimes.com/2023/01/30/upshot/medicare-overbilling-biden-rule.html

By Reed Abelson and Margot Sanger-Katz

Jan. 30, 2023

4 min read

The Biden administration announced a rule Monday cracking down on Medicare private plans that have overcharged the federal government. The rule calls for a more aggressive approach to how plans are audited in the Medicare Advantage program, which enrolls nearly half of all Medicare beneficiaries.

The administration said it expects to collect as much as $4.7 billion over a decade from its heightened oversight. The rule strengthens the ability of the government to audit plans and recover the overpayments. It is the government’s strongest action against the practices in more than a decade.

‘The Cash Monster Was Insatiable’: How Insurers Exploited Medicare for Billions

Oct. 8, 2022

At a news conference announcing the change, Xavier Becerra, the health and human services secretary, acknowledged that Medicare had been criticized for not taking a hard enough stand against the plans’ pattern of overcharging. “Today, we are taking some long-overdue steps to move us in the direction of accountability,” he said.

As Medicare Advantage has become increasingly popular with older Americans, he said the agency needed to make sure it was properly overseeing the private plans. “We want to encourage correct reporting across the program,” he said.

Health insurers had lobbied heavily against the policies in the rule, which relate to a system of risk adjustment, and are likely to bring legal action against the government. Mr. Becerra said he could not speculate on any potential litigation, but he emphasized he thought the new rule was ready “for prime time.”

Insurers were upset by the rule. “This rule is unlawful and fatally flawed, and it should have been withdrawn instead of finalized,” said Matt Eyles, president of AHIP, a large insurer trade group, in a statement.

Health Care in the United States

• Medicare: The Biden administration announced a rule targeting Medicare private plans that overcharge the federal government. The change strengthens the ability to audit plans and recover overpayments.
  

 

Evidence from government audits, fraud lawsuits and academic analysis has shown that many plans have been systematically overcharging the federal government for years by exaggerating the health problems of their customers to collect extra payments. But the Centers for Medicare and Medicaid Services, which regulates the plans, has been reluctant to tackle the overcharging in the face of industry opposition, technical complexity and the plans’ popularity.

Under current rules, regulators have been closely reviewing a small subset of patient medical records to compare them with billing codes sent to the federal government. Under the new policy, the error rate found in the sample will be extrapolated across all the records in the plans since 2018, a change that would substantially increase the magnitude of possible repayments. Officials said plans owe the government $479 million in overpayments from 2018 alone.

 

The extrapolation approach was first proposed in 2018 by the Trump administration. Monday’s regulation makes the new audit system final. But the original proposal would not have made the payments retroactive. “It’s appropriate to have extrapolation going forward,” said Seema Verma, who was the C.M.S. administrator when the rule was first proposed in 2018. But she said the retroactive nature of the rule was “extremely unfair and problematic.”

“They’re likely to get sued,” she said

But some industry critics had been calling for Medicare to go even further, applying the broader penalties as far back as 2011, when the audits began.

“At least we’re on the right track now,” said Ted Doolittle, a former senior Medicare official, who said he was disappointed the agency had gone back only to 2018. But he commended federal officials for their decision to extrapolate from the results of the audits.

The rule also does not include a formula adjustment that insurers had asked for, which would have reduced the penalty amounts in some cases. Medicare officials said the change was not necessary.

Medicare Advantage plans have become popular and are expected to cover the majority of Medicare beneficiaries by the end of this year. They often offer customers lower premiums than the government Medicare plan, and they cover additional benefits like dental care. Plans have warned that regulations that reduce payments to the plans could erode their ability to offer such extra benefits.

The plans have become a major profit center for insurance companies. They earn more gross profit on Medicare plans than other types of insurance, according to a study from the Kaiser Family Foundation, a research group unaffiliated with the insurer Kaiser.

In the press call, Dara Corrigan, the C.M.S. director of the center for program integrity, emphasized that even the billions in estimated recoveries from the plans were small compared with the scope of the program. She said the estimated $4.7 billion in recovered overpayments represented one fifth of one percent of federal payments to the plans over the period.

The audits will focus on extra payments the plans receive when they care for patients who have serious health conditions. The extra payments are meant to compensate the companies for the additional costs associated with treating sicker patients, as part of risk adjustment. But identifying additional diagnoses in order to collect the extra payments has become a major strategic goal of industry players, which use software, home health visits and other measures to maximize the number of diagnoses for each patient, evidence has shown.

Three of the five largest insurers in the industry have been accused of fraud by the Justice Department for inflating diagnoses.

Medicare has come under particular criticism for its handling of audits. The audit details were secret until Kaiser Health News was able to review summaries of the examinations from 2011 to 2013 after it settled a three-year Freedom of Information Act lawsuit against the agency last fall. The reporting estimated there were millions of dollars in overpayments that would mean billions of dollars in penalties if they were extrapolated broadly.

Insurance companies have long defended the current system of risk adjustment as essential to making sure health plans do not discriminate against older adults with potentially expensive illnesses. “Risk adjustment is critical in providing broad and equitable access to care for seniors,” said Tim Noel, UnitedHealthcare’s C.E.O. for Medicare and retirement, before the rule was announced.

AHIP warned in a 2019 letter outlining its objections that “seniors and hardworking taxpayers might see higher costs, reduced benefits, and fewer” Medicare Advantage plan options.

The group went on to question whether Medicare officials had the legal authority to extrapolate widespread errors from a limited audit and collect overpayments from mistakes made years before.

The rule was released Monday after the closing of markets. Many of the major insurers are public companies, and investors have been awaiting its release.

“The managed care companies will challenge the rule but, in any event, it’s only a slight negative for the stocks,” said Les Funtleyder, a health care portfolio manager at E Squared, which holds shares of UnitedHealth Group, in an email. “It could have been worse.”

Reed Abelson covers the business of health care, focusing on health insurance and how financial incentives affect the delivery of medical care. She has been a reporter for The Times since 1995. @ReedAbelson

Margot Sanger-Katz is a domestic correspondent and writes about health care for The Upshot. She was previously a reporter at National Journal and The Concord Monitor and an editor at Legal Affairs and the Yale Alumni Magazine. @sangerkatz • Facebook 

 

 

 

 

jjj

Our Pensions: A Wall Street Time Bomb - The Lever

 https://www.levernews.com/email/cddb30eb-8ff7-4f26-9890-54e0996437c9/?ref=lever-daily-newsletter

A Wall Street Time Bomb

Feb 3, 2023 • The Lever

After reaping huge fees off workers’ savings, private equity firms’ subterfuge could imperil promised benefits for millions of workers and retirees.

 

By David Sirota

As public officials across America prepare to funnel even more of government workers’ savings to private equity moguls, an alarm just sounded for anyone bothering to listen. It is a warning that Wall Street executives want you to ignore as they skim fees off retirement nest-eggs – but the longer the warning goes unheeded, the bigger the financial time bomb may be for workers, retirees, and the governments that pay them.

Earlier this month, Pitchbook — the premiere news outlet for the private equity industry — declared that “private equity returns are a major threat to pension plans' ability to pay retirees in 2023.”

With more than one in ten public pension dollars invested in private equity assets — and with states continuing to keep their private equity contracts secret — Pitchbook cited a new study finding that losses from the investments may be on the horizon for retirement systems that support millions of teachers, firefighters, first responders, and other government employees.

“Private equity returns get reported on a lag of up to six months, and with each update in 2022 values were coming down — which means 2022 numbers were including overstated private equity asset valuations and 2023 numbers are going to incorporate those losses,” noted the study from the Equable Institute.

To comprehend this time bomb, you have to understand private equity’s business model.

In general, private equity firms use pension money to buy up and restructure companies to then sell them at a higher price than they were purchased. In between buying and selling, there are no transparent metrics for valuing the purchased asset — private equity firms can manufacture an alleged value to tell pension investors (and there’s evidence they inflate valuations when seeking new investments).

In a story about an investor receiving two different valuations for the same company, Institutional Investor underscored the absurdity: “Everyone Wants to Know What Private Assets Are Really Worth. The Truth: It’s Complicated.”

Meanwhile, valuation and fee terms in contracts between private equity firms and public pensions are kept secret, exempt from open records laws.

With that in mind, the new warnings are simple: Private equity firms may have told their pension officials that their assets were worth much more than they actually are, all while the firms were skimming billions of dollars of fees off retirees’ money.

If writedowns now happen, it could mean that when it’s time to sell the assets to pay promised retiree benefits, pension funds would have far less money available than private equity firms led them to believe. At that point, there are three painful choices: cut retirement benefits, slash social programs to fund the benefits, or raise taxes to recoup the losses.

Signs of a doomsday scenario are already evident: Some of the world’s largest private equity firms have been reporting big declines in earnings, and federal regulators are reportedly intensifying their scrutiny of the industry’s writedowns of asset valuations. Meanwhile, one investment bank reported that in its 2021 transactions, private equity assets sold for just 86 percent of their stated value last year.

But while pensioners may be imperiled, Wall Street executives are protected thanks to their heads-we-win-tails-you-lose business model: Some of the firms managing pensioners’ money are reporting asset losses for investors, while raking in even more fees from investors and continuing to raise executives’ pay.

Meanwhile, even as some sophisticated private investors rush to get out of private equity, the world’s largest private equity firm, the Blackstone Group, recently reassured Wall Street analysts that state pension officials will continue using retirees’ savings to boost revenues for private equity firms, hedge funds, real estate funds, and other so-called “alternative investments.”

“The desire for alternatives remains very strong,” said Blackstone president Jon Gray in an investor call last week. “Here in the U.S., New York’s state legislature actually increased the allocation for the big three pension funds here by roughly a third.”

Gray was referring to New York Democratic lawmakers passing legislation significantly increasing the amount of retiree money that pension officials can deliver to Wall Street. The bill was championed by New York City Comptroller Brad Lander, just weeks after the Democrat won office promising he would be “reviewing the funds’ positions with risky and speculative assets including hedge funds, private equity, and private real estate funds.”

New York Gov. Kathy Hochul (D) quietly signed the legislation on the Saturday before Christmas, just weeks after the Wall Street Journal reported that analysts have started warning pension funds of looming private equity losses. New York lawmakers simultaneously rejected separate legislation that would have allowed workers and retirees to see the contracts signed between state pension officials and Wall Street firms managing their money.

The Empire State is hardly alone in continuing to use retirees’ money to enrich the planet’s wealthiest financial speculators — from California to Texas to Iowa, pension funds controlling hundreds of billions of dollars of workers’ retirement savings are planning to dump more money into private equity, while keeping the terms of the investments secret.

While globetrotting to elite conferences in exotic locales, pension officials have defended the high-fee investments by parroting Wall Street executives’ claim that private equity reliably outperforms low-fee stock index funds. At the same time, those officials continue to conceal the terms of the investments, raising the question: If the investments are so great, why are the details being hidden?

Perhaps because the investments aren’t as wonderful as advertised: In a landmark study entitled “Private Equity Returns & The Billionaire Factory,” Oxford University’s Ludovic Phalippou documented that private equity funds “have returned about the same as public equity indices since at least 2006,” while extracting nearly a quarter trillion dollars in fees from public pension systems.

In all, a Yahoo News analysis found that pension systems had paid more than $600 billion in fees for hedge fund, private equity, real estate and other alternative investments over a decade.

“The big picture is that they’re getting a lot of money for what they’re doing, and they’re not delivering what they have promised or what they pretend they’re delivering,” Phalippou told The New York Times in 2021.

Even some on Wall Street admit the truth: A J.P. Morgan study in 2021 found that private equity has barely outperformed the stock market, but it remains unclear whether that “very thin” outperformance is worth the risk of opaque and illiquid investments whose actual value is often impossible to determine — investments that could crater when the money is most needed.

While the warnings have not halted the flood of pension cash to private equity, they have broken through in at least some corners of American politics.

For instance: The Securities and Exchange Commission is right now considering new rules to require private equity firms to better disclose the fees they are charging.

Similarly, Ohio’s Republican Auditor Keith Faber just issued a report sounding an alarm about state pension officials keeping their private equity contracts concealed from retirees and the general public — a practice replicated in states across the country.

In New York, Democratic Assemblyman Ron Kim is preparing to reintroduce his bill ending the open records exemption for private equity contracts.

Tip Jar

And following a pension corruption scandal in Pennsylvania — whose state government oversees nearly $100 billion in pension money — there’s a potential financial earthquake: During his first week in office, Gov. Josh Shapiro (D) promised to reprise his move as a county executive and push to shift pensioners’ money out of the hands of Wall Street firms, which raked in more than $1.7 billion in fees in a single year from one of the state’s pension funds.

In perhaps the harshest language ever uttered on the topic by any governor, Shapiro told his state’s largest newspaper: “We need to get rid of these risky investments. We need to move away from relying on Wall Street money managers.”

Shapiro could face opposition not only from private equity moguls and their lobbyists — but also from the pension boards’ union-affiliated trustees. As the Philadelphia Inquirer reported: “Union members [on the boards] have mostly favored the old strategy of private investments, even when challenged by governors’ reps and the last couple of state treasurers.”

When investment returns were somewhat better, that unholy alliance between some unions and Wall Street firms flew under the radar, even as pension funds were ravaged by fees. Same thing for pension funds’ overall investment strategy that has been sending more and more retiree’ savings to private equity firms.

But with warnings of writedowns and losses getting louder — and with Wall Street’s own trade publications sounding alarms — the dynamic could change.

Better late than never — though the later it gets, the bigger the risk for millions of workers and retirees.

 

Medicare Advantage commits the perfect crime - Fred Klonsky

 

Medicare Advantage commits the perfect crime.

Fred Klonsky

10 hr ago

Florida is the destination for thousands of college kids and other young people during Spring break.

But in late January the restaurants and rentals along the Gulf Coast where we are for just a few more days are filled with older folks like us.

They call us snow birds.

Most here now are on Medicare for which we have paid for over a life-time of work.

Many are enrolled in one or another Medicare Advantage private, for-profit insurance plan that has come to dominate the industry and threatens the government retiree healthcare safety net.

It now appears that these for-profit MA plans have committed the perfect crime. They’ve been caught stealing millions of taxpayer dollars but may never have to pay it back.

In 2018, Central Management Services, the federal agency that is supposed to have oversight of MA plans, said it paid $54 million annually to conduct 30 MA plan audits.

The audits uncovered systematic over-billing of the government for services never provided or provided at costs way below what they were charging.

What commonly happens with a government audit is that they extrapolate from a smaller number of cases.

The cost of looking into each and every case is financially and logistically unsustainable.

According to Kaiser Health News:

The estimate for the 2011-13 audits was based on an extrapolation of overpayments found in a sampling of patients at each health plan. In these reviews, auditors examine medical records to confirm whether patients had the diseases for which the government reimbursed health plans to treat.

Through the years, those audits — and others conducted by government watchdogs — have found that health plans often cannot document that they deserved extra payments for patients they said were sicker than average.

The decision to take earlier audit findings off the table means that CMS has spent tens of millions of dollars conducting audits as far back as 2011 — much more than the government will be able to recoup.

Instead, CMS announced it would require next to nothing from insurers for any excess payments they received from 2011 through 2017.

CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted.

Who knows when that will be?

While the decision could cost Medicare plans billions of dollars at some unknown time in the future, it will take years before any penalty comes due.

Health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018.

Exactly how much is not clear because audits as far back as 2011 have yet to be completed.

Without extrapolation for years 2011-17, CMS won’t every retrieve the costs of MA over-billing.

The perfect crime.

Private healthcare sucks.

Fred Klonsky in Retirement is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.

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Breaking Points Exposes Big Pharma and Healthcare Farce

Two videos from Breaking Points Jan. 31, 2023 edition, expose the horrors of our healthcare system. Saagar talks about the $114 billion scam on a drug that was costing 50k a year and now is 80k - with Medicare paying $2 billion. You don't hear the Republicans talking about how they could cut the budget this way - or even Democrats bringing it up. Ya think big pharma may have lobbyists?

https://youtu.be/LNd8Elzazpk?t=2337

 

 

This one from Krystal goes into the 100 million people going blind who could have their vision saved by a simple 10 minute operation. When someone covered it he got criticized - by some progressives. Crazy. 

 https://youtu.be/LNd8Elzazpk 

PRIOR AUTHORIZATION: Denials are way up; doctors are burning out, pleading with officials for help

 

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All the things you need to know in health care.

Wendell Potter Jan 30

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PRIOR AUTHORIZATION: Denials are way up; doctors are burning out, pleading with officials for help

Cost of Denials Saw 67% Increase in 2022

HealthLeaders Media reports that:

City Workers Losing Patience With Slow Crawl to Union Contracts - the city

 

 “Garrido and other union leaders are getting vocal pushback from their ranks — and not just from retirees who would be immediately affected by health coverage changes.”

https://www.thecity.nyc/2023/1/27/23573639/public-employees-overdue-union-contracts

Unions

City Workers Losing Patience With Slow Crawl to Union Contracts

In the second year of the Adams administration, public employees are asking when raises might be coming — but a bitter and costly fight over retiree health care isn’t over.

By Claudia Irizarry Aponte  cirizarry@thecity.nyc

  Jan 27, 2023, 5:05am EST

 

DC 37 Executive Director Henry Garrido, who seeks a new contract for his union’s members, attended the mayor’s State of The City speech, Jan. 26, 2023.

Ben Fractenberg/THE CITY

Most city employees are now working under expired labor contracts that lapsed as far back as 2020 — frustrating rank-and-file union members whose anticipated pay raises are tied up in an escalating battle over proposed changes to retired colleagues’ health coverage. 

Nearly all of the city’s roughly 300,000 unionized staff are working under expired collective bargaining agreements. They include members of the city’s largest public sector unions, District Council 37 (DC37) and the United Federation of Teachers (UFT). Administrative workers, school crossing guards, teachers, police detectives, sanitation workers and health technicians are among those eager to bargain for raises as well as potential new benefits, such as flexibility to work remotely.

That their adversary, Mayor Eric Adams, is himself a former city worker who emphasized his background on the campaign trail and collected many union endorsements only adds to their frustration, especially for those who helped keep the city going during the worst of COVID.

“I think that he misrepresented himself to the unions,” said a delegate to DC37 who declined to give their name as they are not authorized to speak publicly about the issue. Delegates are elected to represent their locals at the 300-member Delegates Assembly and are themselves in charge of electing the union’s leadership.

Said Barbara Randolph, a nurse at Lincoln Hospital in The Bronx: “He won’t be mayor for too much longer if he won’t back the union.” The New York State Nurses Association contract with the city’s public Health+Hospitals system expires March 2.

A roadblock: Retired city workers successfully sued to derail Adams’ plan to move retiree health care to a cheaper alternative called Medicare Advantage and charge a monthly fee to those who wish to retain existing coverage. A City Council bill pushed by Adams that would allow him to roll out Medicare Advantage, which he says would save the city $600 million a year, is “dead,” the Daily News reported last week.

That leaves Adams hundreds of millions of dollars short. The planned Medicare Advantage shift originated in deals struck by former Mayor Bill de Blasio and the unions to pay for raises by finding health care savings. As long as that money remains in limbo, new contract negotiations are going nowhere.

“Our contract is not being negotiated until this is resolved,” said the District Council 37 delegate. “That’s what we’ve all been told.” Some public sector union leaders have also said that the health care talks have stood in the way of bargaining a new contract for their members.

Medicare Mess

The executive director of DC 37, Henry Garrido, also co-chairs the Municipal Labor Committee, the consortium of public employee unions that agreed to the health savings deals. He declined to speak about the standoff or his members’ frustrations.

“We don’t bargain in the press,” said Garrido, who declined to comment further. 

Garrido and other union leaders are getting vocal pushback from their ranks — and not just from retirees who would be immediately affected by health coverage changes.

Five chapters of DC37 Local 375 — which represents city planners, engineers and architects — wrote in a Jan. 9 letter to City Council labor committee chair Carmen de la Rosa that they did not support the Medicare Advantage switch and urged her to kill the proposal. DC37 Local 768, which represents therapists, exterminators, and other health technicians, also urged its membership to pressure their City Council members to strike down the bill.

A City Hall spokesperson said the Adams administration is “committed to offering quality and sustainable care for our retirees.

“The city and the Municipal Labor Committee worked together to take advantage of the federal funding for Medicare Advantage plans that would permit us to continue providing high-quality, premium free coverage for retirees while saving approximately $600 million a year — savings that are especially critical as we continue to face a skyrocketing health care crisis and other fiscal challenges,” mayoral spokesperson Jonah Allon said in a statement. 

Pointing to a recent Council hearing on the bill that would break the Medicare Advantage logjam, Allon added: “We presented a clear case that the city’s Medicare Advantage plan would offer myriad improvements over the current SeniorCare plan, while still encouraging the Council to preserve retiree choice by amending the administrative code.”

Health Care Costs

Marianne Pizzitola, an FDNY retiree and president of the NYC Organization of Public Service retirees, the nonprofit behind the lawsuit, urged the mayor and the Municipal Labor Committee to find another way to reach health care savings.

“This is not being supported by the City Council, it’s not appreciated by our seniors. Let’s do something else. Let’s go back to the bargaining table and figure something out,” she told THE CITY.

The last mayor to let contracts lapse was Michael Bloomberg, who refused to settle with any of the city’s 152 labor unions, effectively leaving those negotiations to his successor.

That was Bill de Blasio, who worked quickly to settle expired contracts upon taking office in 2014, reaching a deal with the UFT that May and DC37 soon after. (Just one union remains at sea: the Marine Engineers Beneficial Association, which represents Staten Island Ferry captains and mates, has not had a contract for more than a decade.) The health savings pact, and that $600 million in savings, was a critical piece of the puzzle — one Adams is now trying to solve. 

Mayors traditionally settle labor agreements first with the largest unions, UFT and DC37, which represent about 60% of city employees, setting a pattern that smaller unions then follow in their own negotiations. 

Members and sponsors make THE CITY possible.

The Adams administration recently began preliminary talks with DC37, whose contract covering 100,000 workers expired in 2021. The loss of expected health savings means money is not flowing into a special health insurance fund that the city and unions jointly administer to help pay for member benefits.

“The unsettled nature of the Medicare Advantage program as well as the overall fiscal health of the Health Insurance Stabilization Fund is an impediment to moving forward with regular labor negotiations,” said Ana Champeny, the vice president for research at the nonprofit Citizens Budget Commission.

She added that rising health care costs need to be dealt with, somehow. 

“The entirety of how the city finances, pays for and provides health insurance benefits and welfare fund benefits to the public sector — both current employees and retirees — needs a close reevaluation,” she said. Collective bargaining, she added, is where these issues will play out.

Reserves and Rainy Days

Experts at the Independent Budget Office, an official fiscal watchdog, say that the steep costs associated with past commitments to help unions pay for GHI Emblem Health, the plan most city workers have enrolled in since the 1940s, are bound to continue piling up. Since the 1980s, city union contracts have only guaranteed funding for an insurance plan that is typically cheaper, called HIP — and making up the difference has become a ongoing scramble.

“There are always trade-offs in any particular budgetary decision,” said IBO assistant director for budget review Logan Clark. “As long as GHI remains more expensive than HIP/HMO, then we’re going to be dealing with this problem sort of in perpetuity.” He called the gap between HIP and GHI premiums “a continuing hole that we will always have to be filling in.”

But there are options to fill the budget gap, at least for the short term, he said. The city could tap into its general reserves, funds set aside every fiscal year, or the Temporary Benefits Trust, a $3.4 billion reserve. 

“That’s something that they could be tapped into as part of the reserves, either by paying down or essentially making smaller payments into next year’s payments for retiree health benefits,” said Clark.

Another option would be dipping into the city’s rainy-day funds – in what would be an unprecedented move because “the promulgation of standards of what constitutes an emergency to tap into the rainy day funds haven’t really been promulgated yet, so that’s something that is certainly up for question,” Clark said.

So far, Adams budgeted enough in his preliminary budget to cover 1.25% annual raises — far below the current 6.3% inflation rate in the New York area.

Adams has used his rank-and-file bona fides to set himself apart from his predecessors, to the annoyance of retirees who sued his administration over the healthcare plan.

Previous mayors, he told an audience of labor leaders at the SOMOS convention in Puerto Rico last November, “never knew what it was like to hold their stomachs when it was time for union contract negotiations. Didn’t know what it was like to fight for their healthcare, to protect their pensions, to be on the union lines to really fight to get the raises you deserve.”

“Like the retirees,” Pizzitola, the president of the NYC Organization of Public Service Retirees, shot back in a moment captured on video.

Arthur Goldstein, a high school ESL teacher who has documented the health care plan saga on his blog, said that he is preparing for a long battle ahead.

“I think we could be without a contract for a very long time.”

How NY Dem Midterm Debacle Unfolded - Loss of House to Republicans Connected to Reason Progressives Rejected Judge

I just gave $100 to The Indypendent - articles like this are the reason.

 

https://indypendent.org/2022/11/how-the-new-york-democrats-midterm-debacle-unfolded/

 

A cascading series of blunders by leading NY Democrats handed half of Congress to the Republicans. Can the state party's dysfunction be reversed?

• John Tarleton Nov 23, 2022

This year’s midterm elections saw the much-anticipated Republican “red wave” turn into a red trickle in most of the country with one glaring exception: bright blue New York.

President Joe Biden won the state by 23 points in 2020. Democrats control all of New York’s statewide offices and wield super-majorities in both houses of the state legislature. National Democrats expected that the party’s control over the once-in-a decade redistricting process would help shore up its razor-thin congressional majority. 

A mighty stream of hubris, incompetence and cronyism laid waste to the New York Dems’ own electoral aspirations and that of Democrats across the country. 

Instead of expanding their majority, New York Democrats lost four congressional seats in an election in which their party didn’t lose more than two seats in any other state. Meanwhile, as The Indypendent goes to press, the Republicans appear headed for a tiny (one to three seat) House majority once all the mail-in votes are counted in California. The New York Dems’ debacle will be the difference between ceding control of the House of Representatives to a MAGA heavy Republican caucus intent on creating partisan gridlock as opposed to continuing Democratic control of the White House and Congress that would make more progressive legislation possible during the second two years of the Biden administration. 

There was no one cause, nor one culprit, for the New York Dems’ face plant. Instead, the causes of their failure flowed into each other as tributaries forming a mighty stream of hubris, incompetence and cronyism that would lay waste to their own electoral aspirations and that of Democrats across the country. 

A Journey in 11 Steps

1. State Senate Leaders Rush a Top Court Pick

Madeline Singas and former New York Gov. Andrew Cuomo at an event supporting an extension of the NY Property Tax Cap. Seaford, NY, June 2015. Photo by Ann Parry

‘Cancel This Failed Experiment’: Physicians Tell Biden HHS To End Medicare Privatization Pilot

 

‘Cancel This Failed Experiment’: Physicians Tell Biden HHS To End Medicare Privatization Pilot

Jake Johnson
January 19, 2023
Common Dreams

• 
• 
• 
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The Medicare privatization program "presents a threat to the integrity of traditional Medicare, and an opportunity for corporations to take money from taxpayers while denying care to beneficiaries," said Physicians for a National Health Program. 

 

A national physician group this week called for the complete termination of a Medicare privatization scheme that the Biden White House inherited from the Trump administration and later rebranded—while keeping intact its most dangerous components.

Now known as the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model, the experiment inserts a for-profit entity between traditional Medicare beneficiaries and healthcare providers. The federal government pays the ACO REACH middlemen to cover patients' care while allowing them to pocket a significant chunk of the fee as profit.

The rebranded pilot program, which was launched without congressional approval and is set to run through at least 2026, officially began this month, and progressive healthcare advocates fear the experiment could be allowed to engulf traditional Medicare.

In a Tuesday letter to Health and Human Services Secretary Xavier Becerra and Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure, Physicians for a National Health Program (PNHP) argued that ACO REACH "presents a threat to the integrity of traditional Medicare, and an opportunity for corporations to take money from taxpayers while denying care to beneficiaries."

The group, which advocates for a single-payer healthcare system, voiced alarm over the Biden administration's decision to let companies with records of fraud and other abuses take part in the ACO REACH pilot, which automatically assigns traditional Medicare patients to private entities without their consent.

CMS said in a press release Tuesday that "the ACO REACH Model has 132 ACOs with 131,772 healthcare providers and organizations providing care to an estimated 2.1 million beneficiaries" for 2023.

"As we have stated, PNHP believes that the REACH program threatens the integrity of traditional Medicare and should be permanently ended," Dr. Philip Verhoef, the physician group's president, wrote in the new letter. "Whether or not one agrees with this statement, we should all be able to agree that companies found to have violated the rules have no place managing the care of our Medicare beneficiaries."

Among the concerning examples PNHP cited was Clover Health, which has operated so-called Direct Contracting Entities (DCEs)—the name of private middlemen under the Trump-era version of the Medicare pilot—in more than a dozen states, including Arizona, Florida, Georgia, and New York.

PNHP noted that in 2016, CMS fined Clover—a large Medicare Advantage provider—for "using 'marketing and advertising materials that contained inaccurate statements' about coverage for out-of-network providers, after a high volume of complaints from patients who were denied coverage by its MA plan. Clover had failed to correct the materials after repeated requests by CMS."

Humana, another large insurer with its teeth in the Medicare privatization pilot, "improperly collected almost $200 million from Medicare by overstating the sickness of patients," PNHP observed, citing a recent federal audit.

"It appears that in its selection process [for ACO REACH], CMS did not prevent the inclusion of companies with histories of such behavior," Verhoef wrote. "Given these findings, we are concerned that CMS is inappropriately allowing these DCEs to continue unimpeded into ACO REACH in 2023."

While the Medicare pilot garnered little attention from lawmakers when the Trump administration first launched it during its final months in power, progressive members of Congress have recently ramped up scrutiny of the program.

Last month, Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) led a group of lawmakers in warning that ACO REACH "provides an opportunity for healthcare insurers with a history of defrauding and abusing Medicare and ripping off taxpayers to further encroach on the Medicare system."

"We have long been concerned about ensuring this model does not give corporate profiteers yet another opportunity to take a chunk out of traditional Medicare," the lawmakers wrote, echoing PNHP's concerns. "The continued participation of corporate actors with a history of fraud and abuse threatens the integrity of the program."

[Jake Johnson is a staff writer for Common Dreams.]

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Medicare Advantage Is a National Scandal - How Thick Could New York City’s Information Bubble Be? Work Bites

 

 https://www.work-bites.com/view-all/1n72juz2psj2e6v48d80bgwyati58c?fbclid=IwAR1yo5uAUf0jpWL723sE2H3PfUvGn-rsymJaC3lr0pWhrF2hwPdFX1p5x5c

Medicare Advantage Is a National Scandal - How Thick Could New York City’s Information Bubble Be?

 

By Joe Maniscalco

Collusion.

That’s what the campaign by New York City Mayor Eric Adams and the heads of the Municipal Labor Committee [MLC] to push municipal retirees into a privatized for-profit Medicare Advantage healthcare program looks like to the many thousands who’ve spent more than a year trying to stop the plan.

What else can a rational human being conclude other than collusion against municipal retirees?

Medicare Advantage is one of the filthiest scandals in America today with lawmakers in Congress calling for the program’s nationwide abolition. And yet, the heads of the biggest city in the country are running around insisting Medicare Advantage is a good deal for retirees.

Really?

How thick would that bubble have to be to keep all that information out?

Work-Bites has already reported on some of the mounting evidence against privatized, for-profit Medicare Advantage plans and the delays, denials and deaths that come with them.

Here’s a little recap: earlier this month, retired Delaware State Senator Karen Peterson told us how “your healthcare can really go off the rails” with Medicare Advantage.

Nevertheless, the powerbrokers in Peterson’s state, as here in NYC, tried to sell municipal retirees on Medicare Advantage, insisting it was “just as good” as what they already had — “only better.”

Turns out, the Medicare Advantage contract Delaware signed with a private healthcare insurance company in September, actually contained 2,030 pre-authorizations — 340 pre-authorizations for medications — and 1,690 pre-authorizations for procedures.

Few things concern dedicated municipal retirees more than suddenly not being able to see their doctor.

A recently-released report from the U.S. Senate Committee on Finance critical of Medicare Advantage chicanery found instances of “provider network confusion” across 10 states where the beneficiary was “switched into a new plan and was unaware that their current doctors were not covered under their new plan’s network until they began to use the new plan.”

Gale Brewer, former Manhattan Borough President and current City Council Member representing the Upper West Side, doesn’t seem to have any problem piercing any sort of Medicare Advantage information bubble.

“The city has offered various Medicare Advantage plans for years,” Brewer said in a statement this week, “but few retirees choose them because they are demonstrably worse than Senior Care.”

She goes on to say, “Medicare advantage plans give private insurance companies the power to overrule primary care physicians — and to say which procedures will be permitted,” she added. “Many retirees have health care issues and work very hard to stay healthy. Keeping their current insurance plan, called Senior Care, is critical in retaining access to their doctors and ensuring continuity of care.”

Gale Brewer gets it.

WHY AREN’T THEY TALKING WITH RETIREES?

That awareness has prompted Brewer to urge all parties involved to “sit down together and work this out.”

Marianne Pizzitola, president of the NYC Organization of Public Service Retirees and Fire Department EMS Retirees Association, has spent months calling for a sit-down with MLC heads Michael Mulgrew, Harry Garrido and Harry Nespoli.

Instead of taking her up on the offer, however, the trio, along wih Mayor Eric Adams — the former Medicare Advantage critic who used to call the program a “bait and switch” — have been pushing pell-mell to privatize the healthcare for tens of thousands of retired trade unionists — raging in the courts, issuing ultimatums, leaning on New York City Council members to tear up part of the City Administrative Code and implementing extra health costs.

Again, all at the precise moment Medicare Advantage plans are being exposed as predatory money grabs and raked across the coals from coast-to-coast.

Brewer correctly characterizes for-hire arbitrator Martin Scheinman’s December 15, filing in favor of the Medicare Advantage switcheroo a “non-binding report.”

Pizzitola is more blunt, calling it “paid propaganda.”

”The December 15th Scheinman report is not a “ruling”, it’s an opinion,” Pizzitola said in a statement released this week. “It’s paid propaganda and they’re hoping the city council falls for it. It is not a decision, it is not a ruling, it is not an award…and yet everyone fell for the biggest play in history…a paid opinion piece!”

Municipal retiree groups have already identified at least $300 million in savings to the City of New York — and none of it necessitates pushing them into a disastrous for-profit Medicare Advantage plan that progressive lawmakers in D.C. say ought to be abolished.

“OMB knows about some of these savings options, and has not implemented them,” Pizzitola says. “Nor have they informed the city council they exist. OMB was unaware of others we suggested in a recent meeting! Which is worse? And yet they told the Mayor’s office there is only one path forward! How can the mayor or the council make a decision if they are not being properly informed by OMB?”

Those leading the charge for Medicare Advantage are some of the most powerful people in the City of New York today. Elderly Municipal retirees are among the weakest and most vulnerable. But they are all hard-working trade unionists who’ve spent their entire working careers in education, the Fire Department, building trades, law enforcement — you name it. Corporate-owned, anti-labor media outlets in this town, as they did in Delaware, are trying to dismiss them all as a small group of crotchety old cranks. We should all remember that and consume our media accordingly.

New York City municipal retirees certainly remember the 2014 pact between former Mayor Bill de Blasio’s administration and UFT President Michael Mulgrew — the faustian deal that allowed $1.3 billion from the city’s Health Stabilization Fund to be used to cover needed raises following a decade of austerity under billionaire Mayor Mike Bloomberg.

They’ve connected all the dots and refuse to be steamrolled by anyone. They simply can’t afford to pretend to live in a Medicare Advantage information bubble. And neither can any of the “retirees in training” following right after them.